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When a slip and fall incident occurs, having an organized approach to documenting the event can make a significant difference. The Slip Fall Incident Report Sample form provides a comprehensive structure for collecting vital details related to the incident. It includes sections that capture essential information such as the date and time of the occurrence, the specific location within the store, and a detailed description of what transpired. Key variables, such as weather and walking surface conditions, help paint a clearer picture of the environment at the time of the fall. Additionally, the form allows for the inclusion of the individual's personal information, including their name, age, and contact details, which is crucial for any follow-up. The issue of bodily injuries is also addressed, with space for detailing the nature of the injury and the treatment that was administered. Witnesses can provide critical insights, which is why the form includes sections for their names and contact information. For ongoing safety, an investigation section prompts inspection of the incident site immediately after the accident, assuring that all conditions, such as lighting and floor mat presence, are recorded. It even requests additional documentation, like the daily floor check log, which can be critical for preventing future incidents. Each of these sections is designed to gather comprehensive information, promoting safety and offering clarity for anyone involved in the incident.

Slip Fall Incident Report Sample Example

SLIP AND FALL INCIDENT REPORT

Store #:

 

 

Store name:

 

INCIDENT INFORMATION

 

 

 

 

Date:

 

Day of week:

 

Time:

Location of incident:

 

 

 

 

Description of incident:

 

 

 

 

AM

PM

Weather conditions: Walking surface conditions: Incident reported when it occurred? If no, how was it report/when?

CLAIMANT INFORMATION

Last name:

Age: Sex: Male If no, explain:

 

First name:

 

Female

If minor, was child supervised?

Yes

No

Address:

Telephone: Home: (_______) _________ - _____________

Business: (_______) _________ - _____________

Why was the customer in store?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What was customer doing prior to the incident:

 

 

 

 

 

 

 

 

Type and condition of footwear:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BODILY INJURY

 

Description of injury:

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment given (if any):

 

 

 

 

 

 

 

 

 

 

 

 

Was the injured person taken to medical facility? Yes

No

If yes, where?

 

 

How was he or she transported? (name of agency)

 

 

Name of attendant:

 

 

6311

WITNESSES

Name:

 

Address:

Phone:

 

Comments:

Name:

 

Address:

Phone:

 

 

Comments:

INVESTIGATION

Was incident site inspected immediately? Yes

No

Time:

 

:

 

AM

PM

Inspected by:

How did we find out about the incident?

Describe conditions at scene:

Describe lighting conditions:

Was photograph taken of accident scene? Were floor mats in place?

Condition of mats:

Yes Yes

No No

If floor was wet, were Caution signs in place?

Yes

No

 

 

Eye glasses being worn?

Yes

No

If yes, type:

 

Cane or walker used?

Yes

No

If yes, why?

 

 

 

 

 

Was injured taking medication?

Yes

No

If yes, why?

 

NOTE: include a copy of the daily floor check log for the date of the accident

ADDITIONAL INFORMATION

Additional paperwork attached:

If yes, describe:

Yes

No

SIGNATURES

Report completed by:

 

 

Signature:

 

Date completed:

 

 

Read and approved by:

 

Disclaimer: This material is designed and intended as general information only. This form was not drafted by an attorney and is not intended, nor shall be 6311

construed or relied upon, as specific legal advice.

Get Slip Fall Incident Report Sample PDF Form

Form Characteristics

Fact Name Description
Reporting Party The form is designed to gather information from witnesses and the claimant regarding the slip and fall incident.
Incident Details It includes critical details such as date, time, location, and a description of the incident for accurate record-keeping.
Claimant Information The form collects personal information about the injured party, including their name, age, and contact information.
Bodily Injury Section This section documents any injuries sustained, treatments administered, and details about medical transport.
Witness Section It facilitates the collection of witness information, which can be crucial for investigating the incident.
State-Specific Requirements Forms may differ by state, governed by local premises liability laws that influence reporting protocols.

Guidelines on Utilizing Slip Fall Incident Report Sample

Completing the Slip Fall Incident Report Sample form is an essential step to document the details surrounding an incident accurately. This report allows for a thorough understanding of what happened and can be important for follow-up actions and potential claims. Follow the steps below to ensure you fill out the form correctly.

  1. Start by entering the store details at the top of the form:
    • Store #: Enter the specific store number.
    • Store name: Write the name of the store where the incident occurred.
  2. Fill in the Incident Information section:
    • Date: Record the date of the incident.
    • Day of week: Specify the day of the week.
    • Time: Indicate the time of the incident, selecting AM or PM accordingly.
    • Location of incident: Describe where the incident took place.
    • Description of incident: Provide a detailed account of what happened.
    • Weather conditions: Describe the weather at the time of the incident.
    • Walking surface conditions: Note the condition of the surface where the slip or fall occurred.
    • Incident reported when it occurred: Specify yes or no. If no, explain how and when it was reported.
  3. Complete the Claimant Information:
    • Last name: Enter the last name of the injured person.
    • First name: Enter the first name.
    • Age: Write their age.
    • Sex: Check the appropriate box for Male or Female.
    • If minor, was child supervised?: Mark Yes or No.
    • Address: Provide the home address.
    • Telephone: Fill in home and business phone numbers.
    • Why was the customer in the store?: Explain the reason for their visit.
    • What was the customer doing prior to the incident?: Describe the activity.
    • Type and condition of footwear: Note what type of shoes were being worn and their condition.
  4. Document Bodily Injury details:
    • Description of injury: Clearly describe any injuries sustained.
    • Treatment given (if any): Note any treatment provided at the time.
    • Was the injured person taken to a medical facility?: Mark Yes or No.
    • If yes, where?: State the location of the medical facility.
    • How was he or she transported?: Specify how the injured person was transported.
    • Name of attendant: Enter the name of the person who assisted.
  5. Gather Witnesses information:
    • Name: Write the names of witnesses.
    • Address: Include their addresses.
    • Phone: List their phone numbers.
    • Comments: Gather any remarks from witnesses.
  6. Provide Investigation details:
    • Was incident site inspected immediately?: Mark Yes or No.
    • Time: Specify the time of inspection.
    • Inspected by: Enter the name of the inspector.
    • How did we find out about the incident?: Describe the source of the information.
    • Describe conditions at scene: Detail the conditions observed.
    • Describe lighting conditions: Note how well the area was lit.
    • Was photograph taken of accident scene?: Indicate Yes or No.
    • Were floor mats in place?: State whether mats were there.
    • Condition of mats: Describe the mats’ condition.
    • If the floor was wet, were Caution signs in place?: Indicate Yes or No.
    • Eye glasses being worn?: Mark Yes or No and provide type if Yes.
    • Cane or walker used?: Mark Yes or No and explain if Yes.
    • Was the injured taking medication?: State Yes or No and explain if Yes.
    • Note: Attach a copy of the daily floor check log for the accident date.
  7. Complete the Additional Information section:
    • Additional paperwork attached: Specify Yes or No and describe if Yes.
  8. Fill in the Signatures section:
    • Report completed by: Enter your name.
    • Signature: Provide your signature.
    • Date completed: Enter the date the report was done.
    • Read and approved by: Enter the name of the approver.

What You Should Know About This Form

What is the purpose of the Slip Fall Incident Report Sample form?

This form serves to document the details of a slip and fall incident that occurs at a store. It collects essential information such as the location, conditions at the time of the incident, and details about the injured individual and their experience. This documentation can be crucial for understanding the circumstances of the incident and addressing any claims that arise from it.

What information do I need to provide in the INCIDENT INFORMATION section?

In the INCIDENT INFORMATION section, you need to include details such as the date and time of the incident, the specific location within the store, a description of what happened, and the weather and walking surface conditions at the time. Additionally, it’s important to note whether the incident was reported immediately and, if not, how and when it was reported.

How do I complete the CLAIMANT INFORMATION section?

This section requires you to fill in personal details about the individual who experienced the slip and fall. This includes their last name, first name, age, and sex. If the individual is a minor, you must note if they were supervised at the time. You should also provide their address and contact numbers for home and business, as well as the reason for their visit to the store and what they were doing before the incident.

What should be recorded under BODILY INJURY?

Under the BODILY INJURY section, detail any injuries sustained during the incident. This includes a description of the injury, if any treatment was administered on-site, and whether the injured party was transported to a medical facility. If they were taken to a medical facility, note where they were taken and how they were transported.

What details are included in the WITNESSES section?

In the WITNESSES section, you should list the names and contact information of any individuals who witnessed the incident. Descriptions of their comments or observations regarding the incident can also be included to provide further context.

How is the investigation section of the form important?

The investigation section helps to determine how the incident was handled post-occurrence. Here, you will note if the incident site was inspected immediately, by whom, and what conditions were observed at the scene. Additionally, any photographs taken, the condition of safety mats, and signage related to the slip hazard should be documented.

What is the significance of the SIGNATURES section?

The SIGNATURES section serves as verification that the report was completed accurately. The person compiling the report must sign and date it, as well as any supervisory personnel who approve the report. This adds credibility to the documentation and assists in maintaining a record of the investigation process.

Common mistakes

When filling out the Slip and Fall Incident Report Sample form, individuals often make mistakes that can significantly impact the outcome of their claims. One common error is failing to provide a detailed description of the incident. A vague description may lead to misunderstandings about what actually occurred. It is essential to provide specific information, including the events leading up to the incident and any contributing factors, such as weather or floor conditions.

Another frequent mistake is neglecting to include the correct treatment information. Individuals sometimes forget to note whether medical treatment was provided or fail to specify the facility where the injured party was taken. This information is crucial as it helps to establish the seriousness of the injuries sustained and can influence the resolution of a claim.

Accurate witness information is vital, yet often overlooked. Report fillers may leave out witness details or fail to include witness statements. Witness accounts can provide an objective perspective on the incident that clarifies the circumstances. Insufficient witness information might weaken a claim, as corroborating statements can significantly bolster the accuracy of the events described in the report.

Finally, people frequently forget to sign the report or provide the date of completion. This oversight might make the report appear incomplete. Ensuring that the document is properly signed and dated demonstrates that the information provided is verified and accepted by the person who filled it out. This step is crucial for maintaining the report's credibility and for its use in any potential claims process.

Documents used along the form

When a slip and fall incident occurs, several documents typically accompany the Slip Fall Incident Report Sample form. Each document serves a unique purpose, providing vital information for investigation and review. Below is a list of these commonly used documents, each briefly described for clarity.

  • Accident Scene Photographs: These images capture the immediate conditions at the incident site. They provide visual evidence of factors such as lighting, floor conditions, and whether warning signs were present.
  • Witness Statements: Written accounts from individuals who witnessed the incident can provide different perspectives and details about what transpired before and during the fall.
  • Medical Reports: If the injured person sought medical treatment, these documents outline the nature of the injuries and any treatments provided, linking the medical findings to the incident.
  • Daily Floor Check Log: This log details regular inspections of the flooring area where the incident occurred, documenting maintenance and safety checks performed on the date of the accident.
  • Incident Follow-Up Reports: After an initial investigation, these reports analyze the incident, noting corrective actions taken to prevent future occurrences and summarizing findings.
  • Insurance Claim Documents: If insurance claims are filed, these documents provide details about the claim process and any compensation sought following the incident.
  • Employee Training Records: Records that show staff training on safety protocols can be relevant, especially if employee negligence is considered in the incident.
  • Store Policy Documentation: Copies of relevant policies on safety and incident reporting help provide context on the responsibilities and expectations in place at the time of the incident.

These documents collectively contribute to a comprehensive understanding of the slip and fall incident. They ensure that all relevant information is captured and considered during the investigation process, ultimately aiding in determining liability and improving safety measures for the future.

Similar forms

  • Accident Report Form: Like the Slip and Fall Incident Report, an Accident Report Form documents details of an incident occurring within a business, including the involved parties, witness accounts, and conditions at the scene. Both forms aim to provide a comprehensive overview of the incident to help in investigations and potential claims.
  • Incident Log: An Incident Log serves a similar purpose by tracking various incidents that take place at a location. It may include various types of incidents beyond slips and falls. Like the slip fall report, it records critical details, timelines, and individuals involved to maintain an accurate history of events for reference.
  • Witness Statement Form: This form gathers firsthand accounts from individuals who witnessed the incident. It complements the Slip and Fall Incident Report by providing additional perspectives and details about the event, which can be crucial for determining liability and understanding circumstances surrounding the accident.
  • Insurance Claim Form: When injuries occur, an Insurance Claim Form often follows to seek compensation for damages. This document differs slightly in its focus on financial aspects but shares similarities in gathering necessary information about the incident, including details of injuries and treatments administered. The two documents can work together to strengthen a claim.

Dos and Don'ts

When filling out the Slip Fall Incident Report Sample form, it is important to follow specific guidelines to ensure accurate and comprehensive documentation. Below is a list of actions to take and avoid.

  • Do provide clear and detailed information about the incident.
  • Do include the exact date and time of the incident.
  • Do specify the location where the incident occurred.
  • Do describe the conditions of the walking surface at the time of the incident.
  • Do document the weather conditions which may have affected the incident.
  • Don't leave any fields blank unless absolutely necessary.
  • Don't speculate on who is at fault for the incident.
  • Don't alter information after it has been submitted.
  • Don't forget to report any witnesses and include their contact information.
  • Don't overlook the need for additional documentation if required.

Misconceptions

Understanding the Slip Fall Incident Report Sample form is crucial for both employees and customers. However, several misconceptions can cloud the effectiveness of this important document. Below are some common misunderstandings, clarified for better awareness.

  • It is only for legal purposes. Many think that the form is solely for legal documentation. In reality, it serves to collect essential information that can help improve safety measures in the store.
  • Anyone can fill it out. While it is tempting to have anyone complete the form, it is best filled out by a trained employee who understands the details necessary for an accurate report.
  • The form is optional. Some believe that completing the form is not necessary. However, documenting the incident promptly can lead to quicker resolutions and better safety practices.
  • Only injuries require reporting. Injuries are important, but any incident, regardless of injury severity, should be documented to improve store safety.
  • Witness accounts are not important. Witnesses provide valuable perspectives. Their accounts can clarify circumstances around the incident and help improve future safety protocols.
  • Weather conditions are irrelevant. The weather can significantly impact safety. Recording this information helps in understanding any external factors that contributed to the fall.
  • Completing the form is a one-time event. The process is ongoing. Regular audits of incident reports can identify trends that warrant safety adjustments.
  • Photos are unnecessary. Visual documentation can provide context that words alone cannot capture. Photographs of the incident site can be crucial for future investigations.

By addressing these misconceptions, individuals can better appreciate the significance and utility of the Slip Fall Incident Report Sample form. Accurate reporting not only aids in resolving specific incidents but also fosters a safer environment for everyone involved.

Key takeaways

Filling out and using the Slip and Fall Incident Report Sample form is an essential step in documenting an accident. Here are some key takeaways to consider:

  • Thoroughness is key: Complete all sections, including the incident information and claimant details. Make sure to include specific descriptions to capture what happened accurately.
  • Timeliness matters: Report the incident as soon as possible. If the report is delayed, note how and when it was eventually submitted.
  • Gather witness information: Collect names, addresses, and comments from witnesses. This information can provide crucial insights into the circumstances of the incident.
  • Include supporting documents: Attach any relevant additional paperwork, like daily floor check logs, to strengthen the report.

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